DHIS2 Generic Structured Feedback via Job-Aids Proposal
University of Oslo, MSI, CHAI, GAVI, HISP SA, UNICEF-ESARO, PSI
The University of Oslo (UiO), Maries Stopes International (MSI), Clinton Health Access Initiative (CHAI), Gavi, the Vaccine Alliance (GAVI), Health Information Systems Program South Africa (HISP SA), UNICEF East and Southern Africa Regional Office (UNICEF-ESARO), and Population Services International (PSI) consortium requests funding for the development and launch of a generic structured feedback job-aid module as a core component of DHIS2. DHIS2’s significant global implementation scale is supporting countries towards improved health outcomes through better use of Health Management Information System (HMIS). However, most of the data available in local DHIS2 instances are related to disease surveillance, and improved health outcomes are only partially achieved if quality of healthcare is not taken into account. In order to improve quality of healthcare with DHIS2, health managers, health providers and community health workers (CHWs) should benefit from tailored on-site feedback after a quality assessment, such a supervision visit, is conducted. By developing the capability to apply structured feedback job-aids as a core functionality of DHIS2, users will be offered the possibility to (i) assess health providers and community health workers (CHWs) against desired outcomes, (ii) improve healthcare performance through tailored on-site feedback via job-aids displayed interactively or shared via common messaging applications and (iii) flag certain conditions that require management attention. This functionality can also be applied to other contexts and scenarios as long as the DHIS2 user desires to trigger a structured feedback job-aid when a condition is met for a DHIS2 object (or a group of DHIS2 objects). This functionality will ultimately support district and national health officers in their performance management activities.
Expected outcomes include (i) the development and launch of core DHIS2 functionality for a generic structured feedback job-aid, and (ii) the promotion and sustained use of the developed functionality in four different contexts to document different use cases of the functionality (i.e. quality of healthcare improvement, management of health commodities, point-of-care treatment, etc.). The primary goal is to establish the desired functionality in core DHIS2 that can be used in different contexts and different health service delivery channels.
UiO, MSI, CHAI, GAVI, HISP SA, UNICEF-ESARO, and PSI propose a one-year period to (i) develop the generic structured feedback job-aid functionality in the core of DHIS2, (ii) launch and pilot its applications in at least four different contexts, and (iii) evaluate the functionality based on users’ feedback in order to further enhance features.
PSI will lead a consortium team composed of:
University of Oslo (UiO) hosts the core DHIS2 software development team, contributes to in-country capacity building and implementation support and promotes DHIS2 as a global public good. UiO brings the technical know-how of DHIS2 as well as the steering direction of enhancements of DHIS2 to better serve the needs of DHIS2 implementers and users. See http://www.dhis2.org for further information.
Marie Stopes International (MSI) is an international non-governmental organisation based in London, UK providing contraception and safe abortion services in 37 countries around the world. MSI as an organisation lobbies in favour of access to abortion, and provides a variety of sexual and reproductive healthcare services including advice, vasectomies, and abortions in the UK and other countries where it is legal to do so.
Clinton Health Access Initiative (CHAI) is a global health organization committed to saving lives and reducing the burden of disease in low-and middle-income countries, while strengthening the capabilities of governments and the private sector in those countries to create and sustain high-quality health systems that can succeed without our assistance. As part of our vision, CHAI works closely with governments to deploy information systems, including DHIS2, to support data collection and management, patient tracking, health surveillance, lab management, and supply chain management across disease and program areas, with a specific focus on building capacity of decision makers in using data and systems effectively for improved health outcomes.
Gavi, the Vaccine Alliance (GAVI) is an international organisation - a global Vaccine Alliance, bringing together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest countries, currently 68. This model was designed to leverage not just financial resources but expertise too, to help make vaccines more affordable, more available and their provision more sustainable, by working towards a point where developing countries can pay for themselves. Coverage and equity are at the core of our strategy and increasing effectiveness and efficiency of immunisation delivery as an integrated part of strengthened health systems is part of our systems goal. Improving quality of immunisation services and use of immunisation data is part of this effort.
Health Information Systems Program South Africa (HISP SA), a South African-based NGO, has over 2 decades of experience in the development and implementation of sustainable and integrated Health Information Systems. HISP SA has become the leader in DHIS2 implementation in South Africa, where systems are well developed, mature and sophisticated, and also through its supporting role to African neighbours and beyond, into 19 other countries.
UNICEF-ESARO is UNICEF’s regional office covering 21 countries in the East and Southern Africa region. UNICEF is a UN organization mandated by the United Nations General Assembly to advocate for the protection of children's rights, to help meet their basic needs and to expand their opportunities to reach their full potential, with offices in 190 countries worldwide. UNICEF has a long term agreement with the University of Oslo on the development of several DHIS2 applications and works with Ministries of Health to contextualize and embed them in national health system processes.
Population Services International (PSI) is a global non-profit public health organization based in Washington, DC and active in promoting healthier lives in 50 country offices. PSI utilizes DHIS2 as the global management information system, with approximately 3,000 users across over 30 countries. Since 2013, PSI has worked closely with the UiO to design and introduce system enhancements. PSI brings skills in DHIS2 implementation, strengthening use of data and staff capacity building. As a nonprofit DHIS2 implementer, PSI brings to the table a wealth of expertise from a system user perspective. See www.psi.org for further information.
PSI is the organizational management lead and point of contact for the proposal.
Poor quality of care results in poor health outcomes. Improving and monitoring the quality of care in the healthcare sector in Low and Middle Income Countries (LMICs) presents unique challenges. Key constraints include the lack of enforcement of standards of clinical procedures and lack of or delayed performance feedback. To address these issues, PSI created an electronic mobile-based Android application linked with DHIS2 used to improve quality of healthcare, the Health Network Quality Improvement System (HNQIS). The application supports healthcare supervisors to (i) assess providers’ and CHWs’ quality of care against clinical standards, and (ii) improve providers’ quality of care through tailored on-site feedback. Launched in 2015, HNQIS has been used to improve quality of care at 8,000 outlets across 13 health areas in the public and private health sectors of 19 countries. Despite these encouraging results, HNQIS is a custom application: this represents a barrier for other DHIS2 users to adopt all or some functionalities that are built into HNQIS and also makes it not sustainable in the long-term due to the maintenance required to update the app when there are new DHIS2 releases.
Examples of structured feedback available in HNQIS:
Examples of job-aids available in HNQIS:
Technical Approach: The need for core DHIS2 functionality supporting a structured feedback job-aid
Building on the experience and results of PSI’s use of HNQIS, the consortium wants to embed into DHIS2 core development a generic version of the HNQIS functionality. This generic functionality can be described as the ability to trigger feedback / present job-aids when a certain condition is met during or after completing an action, i.e. after finishing a supervision, after obtaining certain results during a Data Quality Assessments, etc. As part of the proposed functionality, the collection of feedback suggestions should be shareable via any installed messaging applications in the mobile device.
Possible uses of this functionality include:
Improving quality of healthcare at provider and CHW level by offering tailored, on-site and offline feedback, supported by job-aids after a quality assessment is completed,
Improved management and allocation of health commodities by automatic alerts on stock consumption and caseloads,
Improved management of patient care through treatment algorithms to support medication based on national protocols. This could be amplified with job-aids in the form of medication administration for the patient
The consortium wants to establish structured feedback and job-aid functionality as part of the core DHIS2 functionality, so it can be used in different contexts and through different health service delivery channels to provide automatic feedback when a condition is met during or after the finalization of a DHIS2 event.
The structured feedback job-aid functionality will deliver on the following capabilities:
Display structured feedback when a certain condition is met for a DHIS2 object or group of objects, after or during the completion of an event,
Display interactive job-aids (images, videos, hyperlinks, documents, etc),
Share feedback and job-aids via common messaging applications or channels,
Allow user-friendly configuration of the triggers, messages, and format of the structured feedback to be presented to users.
Current requirements based on HNQIS and discussions with partners suggest that the functionality will be limited to DHIS2 Programs; however during the requirements gathering phase, consortium partners will be open to explore making this functionality applicable to DHIS2 Datasets, as well.
Consortium partners will pilot the functionality in at least four different contexts by sharing frameworks for making use of this functionality for common use cases, including quality improvement.
Lead Consortium Partner
PSI and UiO
Launch and pilot
Consortium partners are committed to inform further functionality enhancements through alternative sources of funding and will undertake the following activities at the end of the one-year milestone:
Workplan and Budget
A preliminary version of the GANTT chart for conceptualizing, developing, launching and evaluating the DHIS2 Generic Structured Feedback via Job-Aids is available here.
Please see attached for Budget and Budget Narrative.
The budget will mainly be utilized to develop and launch the proposed functionality, including some field testing. More extensive field testing and piloting will be conducted using alternative sources of funding from consortium partners. We envision that the funding from this proposal will serve to create the necessary DHIS2 backend logic and associated rendering in DHIS2 standard Android applications. It is our goal that this functionality will provide Ministries of Health and DHIS2 users an added insight on performance management with DHIS2. This will enable them to achieve the desired health outcomes faster. In case long-term support is needed, we will seek core funding from donors and other in-country financing mechanisms.
Including generic structured feedback and job-aids as part of the core DHIS2 system and companion DHIS2 Android App would allow Health Supervisors and other field workers like CHWs to obaing instant, on-site and offline feedback as their conduct their day-to-day work. Feedback and job-aids would be presented to the mobile users as DHIS2 events are conducted or completed, as per the module configuration. The use-cases for the proposed functionality varies greatly according to the context where it gets deployed: examples include providing tailored on-site feedback supported by job-aids after a quality assessment, automatic identification of data quality gaps with suggested tasks for action, and point-of-care treatment algorithms for self-administered drugs. These processes can be enhanced by the inclusion in-app of job-aids.
Digital Square will fund the necessary development work in terms of DHIS2 back-end, DHIS2 front-end and Android, and field testing necessary to release a stable and functioning version of the functionality ready to be adopted by any DHIS2 user.
The number of partners included in the consortium is an indication of how welcome a DHIS2 Generic Structured Feedback via Job-Aids is. Other partners of the global DHIS2 community who have provided positive feedbacks include:
Ryan Williams, Technical Officer at the Global Malaria Programme of World Health Organisation, Geneva, Switzerland
Dr Pascoa Wate, Head of the Department of Maternal and Child Health of the Ministry of Health, Maputo, Mozambique
Dr Trymore Chawrura, Deputy Director of the Ministry of Health and Child Care, Harare, Zimbabwe
Dr Joris Likwela Losimba, Head of the National Malaria Control Program, Kinshasa, DRC
Dr Huy Rekolm, Director of the CNM National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
Global Fund to fight AIDS, Tuberculosis and Malaria representatives in Geneva, Switzerland
World Bank and Save the Children representatives in Yangoon, Myanmar
USAID Sexual and Reproductive Health Department representatives in Washington, DC, USA
Consortium partners are in regular touch with other members of the broader digital health community and will continue seeking feedback and inputs especially during the Conceptualization and Evaluation phases of the proposal. Examples of engagements with the broader digital health community include ongoing joint projects, conferences, workshops and events.
Use of Digital Health Technologies: Use Cases, User Stories
Thanks to the development of the DHIS2 Generic Structured Feedback via Job-Aids, members of the broader digital health community will be able to address a variety of challenges. These include:
MSI: This new functionality will support MSI in its continuous goal to improve the quality of healthcare services received by our clients. All the providers working within MSI are assessed and supervised on regular basis by our Clinical and Operational team in the field on the quality of the services they delivered. By the scale and critical role of these quality assessments, such a functionality could represent a significant step forward for MSI to improve the quality of healthcare services delivered in an efficient manner. Having access to interactive job aids such as video or image will enable our team to provide effective and impactful mentoring to our providers. Furthermore, the automatic triggering of the required job aids based on the results of the assessment has the potential to increase the efficiency of the visit by allowing a smooth feedback interactions.
CHAI: CHAI's global malaria program works to support government malaria programs in over 20 countries around the world, providing day-to-day operational support to programs and building strong relationships over years of engagement to become a trusted partner. As part of this work, CHAI has been working with national and sub-national (provincial/district)-level government staff across countries to provide more effective supervision to improve malaria case management, vector control implementations, commodity management, and monitoring and evaluation. DHIS2 is widely used by the countries we work with as a reporting and surveillance system, with valuable information across malaria program activities. These improved functionality within DHIS2 would particularly be useful to (a) assess health worker practices across malaria activities by using the existing information within DHIS2 and information collected during supervision visits, (b) to provide more targeted guidance on what skills and service delivery need to be improved by health workers, and (c) to provide guidance and mentoring on how to improve these skills and services.
GAVI: GAVI is committed to support countries in improving immunisation services for better access. Interactive Job-Aid App will help disseminate WHO recommended standards for care including immunisation services at the point of services. Majority of the countries supported by Gavi use HSS grant funding for supervision. Digital support for supervision is more than needed to improve their outcome and ensure efficient use of resources. Structured Feedback App that could be used for supervision of immunisation services alone or on integrated manner will be made available for interested countries and can be a game changer in improving quality of care, thus increasing demand for immunisation.
HISP SA: There is progressively growing interest in providing information technology tools to support the work of Community Health Workers (CHWs). HISP SA and its clients in South Africa and other African Countries will benefit from the new functionality to improve the quality of health services provided to clients. Quality of Care are high on the agenda of the National Health Insurance initiative in South Africa and efforts to ensure quality of care to clients could gain major support in South Africa. Guidelines for specific disease management protocols exist but individual clinicians are not assessed on how well they execute these guidelines, mainly because this is a time consuming exercise and there are not remedial training aids available. South Africa is rolling out a CHW initiative to measure their performance and this functionality will compliment the existing work. Having access to an assessment tool and interactive job aids such as video or images will enable us to strengthen the quality of care provided to clients.
UNICEF-ESARO: UNICEF has been working with UiO on the development of three apps for DHIS2: 1) a Scorecard app to provide an overview of relative performance on key indicators at different levels of the health system to improve accountability for results, 2) A Bottleneck Analysis app to facilitate a systematic method of using data to inform health planning and monitoring, particularly at the district-level, and 3) a linked Action Tracker app to support the monitoring of health plans and analysis of their effect in reducing health system bottlenecks. Each of these applications could benefit from this new functionality by linking specific conditions to follow-up prompts. For instance, if performance on scorecard or bottleneck indicators varies by an unreasonable amount for period to period, this could be flagged for corrective action. Or, if actions to remedy bottlenecks are significantly off track, management could be prompted to take action. In addition, this functionality will be beneficial to our work to support improved clinical care and decision making for maternal and newborn health.
PSI: The use of the HNQIS app has contributed to better health outcomes by improving quality of health service provision. Feedback on the use of the HNQIS app includes: 1) Health provider in Kenya: “I like the videos since I remember what I see more than what I am told. It also takes a short time to receive feedback; then I can get back to attending to the rest of my patients.”, 2) Health supervisor from Mozambique: “I like using the tablet because it’s quick, easy and practical. Also, I can show and discuss results with nurses directly on the tablet and I can forget about papers, even when I have to share action plans. I wish we had more videos in the app.”, and 3) National QA officer from Uganda: “Using data properly is powerful. HNQIS and DHIS2 unquestionably optimize the process of reading data and enhancing support supervision by driving evidence-based decisions, changing system designs, and combatting low skill levels.” Maintenance and upgrade costs make the app not sustainable in the long-term. The development of the proposed functionality will enable the configuration of a metadata package that can be easily deployed as a generic Quality Improvement app that can be adopted by any DHIS2 user for conducting supportive supervision visits into their local DHIS2 instance.